International Journal of
Environmental Research
and Public Health
Review
Surgical Interventions for Inferior Turbinate Hypertrophy:
A Comprehensive Review of Current Techniques
and Technologies
Baharudin Abdullah *






Citation: Abdullah, B.; Singh, S.
Surgical Interventions for Inferior
Turbinate Hypertrophy: A
Comprehensive Review of Current
Techniques and Technologies. Int. J.
Environ. Res. Public Health 2021, 18,
3441. https://doi.org/10.3390/
ijerph18073441
Academic Editor: U
Rajendra Acharya
Received: 28 February 2021
Accepted: 24 March 2021
Published: 26 March 2021
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4.0/).
Int. J. Environ. Res. Public Health 2021, 18, 3441. https://doi.org/10.3390/ijerph18073441
and Sharanjeet Singh
Department of Otorhinolaryngology-Head & Neck Surgery, School of Medical Sciences, Universiti Sains
Malaysia, Kubang Kerian 16150, Kelantan, Malaysia; sharanleyl80@gmail.com
* Correspondence: profbaha@gmail.com
Abstract: Surgical treatment of the inferior turbinates is required for hypertrophic inferior turbinates
refractory to medical treatments. The main goal of surgical reduction of the inferior turbinate is to
relieve the obstruction while preserving the function of the turbinate. There have been a variety
of surgical techniques described and performed over the years. Irrespective of the techniques and
technologies employed, the surgical techniques are classified into two types, the mucosal-sparing
and non-mucosal-sparing, based on the preservation of the medial mucosa of the inferior turbinates.
Although effective in relieving nasal block, the non-mucosal-sparing techniques have been associated
with postoperative complications such as excessive bleeding, crusting, pain, and prolonged recovery
period. These complications are avoided in the mucosal-sparing approach, rendering it the preferred
option. Although widely performed, there is significant confusion and detachment between current
practices and their basic objectives. This conflict may be explained by misperception over the myriad
of available surgical techniques and misconception of the rationale in performing the turbinate
reduction. A comprehensive review of each surgical intervention is crucial to better define each
procedure and improve understanding of the principle and mechanism involved.
Keywords: inferior turbinate hypertrophy; turbinectomy; turbinoplasty; laser; cryotherapy; electro-
cautery; radiofrequency; microdebrider; coblation
1. Introduction
Chronic nasal obstruction is caused by either nasal or septal deformities as well as
mucosal disease associated with turbinate hypertrophy. Turbinate hypertrophy is observed
in various conditions, including allergic rhinitis, vasomotor rhinitis, and infectious rhinitis.
Medical treatments such as antihistamines, topical decongestants, and topical corticos-
teroids are commonly used to treat those conditions, principally to reduce nasal obstruction
and restore comfortable nasal breathing [1]. However, not all patients may respond to
those medications. There might be slight improvement, or in some cases, there is no
response at all and they end up experiencing persistent nasal block. Surgical reduction
of the inferior turbinate is warranted to relieve the nasal block caused by the hypertro-
phied inferior turbinates. Surgical reduction of the inferior turbinate involves removal
of the mucosa, soft erectile tissue, and turbinate bone. Different techniques have been
applied to increase the nasal airway passage, such as conventional turbinectomy, laser
turbinectomy, cryoturbinectomy, electrocautery turbinectomy, conventional turbinoplasty,
microdebrider turbinoplasty, coblation turbinoplasty, radiofrequency turbinoplasty, and
ultrasound turbinoplasty. Overall, the surgical techniques are classified into two types,
the mucosal-sparing and non-mucosal-sparing, based on the preservation of the medial
mucosa of the inferior turbinate (Table 1).
https://www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2021, 18, 3441 2 of 15

Table 1. Type of surgical technique for turbinate reduction.

Nonmucosal Preservation Surgery Mucosal Preservation Surgery

Conventional turbinectomy (partial or total) Conventional turbinoplasty
Electrocautery turbinectomy Microdebrider turbinoplasty
Laser turbinectomy Coblation turbinoplasty
Cryoturbinectomy Radiofrequency turbinoplasty
Ultrasound turbinoplasty

Conventional turbinectomy (total or partial) is considered very effective in relieving

nasal block. Due to the excessive loss of tissue (bone and mucosa), the postoperative
complications include excessive bleeding requiring blood transfusion, crusting, pain, and
prolonged recovery period. Hence, a more mucosal-friendly approach is preferred; the
turbinoplasty procedure, which resects either soft tissue or bone or both with preservation
of the mucosa. Additionally, out-fracture of the turbinate may be performed to augment
the other procedures. With the availability of the videoendoscopic system, the majority of
the surgical techniques are currently being performed endoscopically. Irrespective of the
techniques, the aims are to obtain relief of nasal obstruction, preserve the function of the
turbinate, and avoid complications such as bleeding, crusting, and excessive pain [2]. To
achieve this, adequate inferior turbinate tissue must be removed while avoiding excessive
turbinate mucosa resection. In this review, we define each surgical technique to highlight
the principle and mechanism involved in each procedure.

1.1. Surgical Anatomy of the Inferior Turbinate

The inferior nasal turbinate consists of turbinate bone, mucoperiosteum, soft erectile
tissue, and mucosa [3]. The irregular turbinate bone is interspersed with blood vessels and
covered by the mucoperiosteum. It is located at the inferior part of the nose extending
from the anterior nostril to posterior choana. The turbinate bone is connected to the palate,
ethmoid, and lacrimal sac. The inferior nasal turbinate is expansible due to the presence of
the submucosal cavernous plexus, especially well developed at its anterior part. Among
the triggering factors are allergy, infection, or hormonal changes, causing engorgement of
the turbinates. Permanent hypertrophy occurs due to persistent and excessive stimulation.
The inferior turbinate is supplied by inferior thyroid artery (ITA), a branch of the
posterior lateral nasal artery [4]. The inferior thyroid artery enters the inferior turbinate at
its posterosuperior end, where it divides into two or three branches. It courses through
the inferior turbinate in a bony canal wrapped by a fascial coat binding the ITA and canal
tightly. This relation is the main reason for the prolonged bleeding following turbinate
surgery, as the fascial coat prevents the ITA from contracting.

1.2. Evaluation of the Inferior Turbinate Hypertrophy for Surgical Intervention

There are several classification systems for inferior turbinate hypertrophy. Three of
them are based on clinical examination of the inferior turbinate size, while one is based
on computed tomography scan imaging [5–8]. To assess the outcome of submucous
resection in their patients, Friedman et al. [5] used the three-grading system; grade 1 is
mild enlargement with no obvious obstruction, grade 2 is incomplete obstruction, and
grade 3 complete occlusion of the nasal cavity. A study correlating the nasal anatomy to the
severity of obstructive sleep apnea classified inferior turbinate hypertrophy as 0—normal,
1—mild, 2—moderate, or 3—severe [6]. Camacho et al. [7] classified the inferior turbinate’s
size as four grades based on its position in the total nasal airway space as visualized on
nasoendoscopic assessment. When the inferior turbinate occupies 0 to 25% of total airway
space, it is grade 1, grade 2 is 26% to 50%, grade 3 is 51% to 75%, and grade 4 is 76% to
100% (Figure 1). By studying the inferior turbinate bone using computed tomography,
Uzun et al. [8] rated the inferior turbinate size as type 1 (lamellar), type 2 (compact
bone), type 3 (combined), and type 4 (bullous). There is no consensus or standardization
on the ideal classification system, and this creates difficulty and confusion in assessing
Int. J. Environ. Res. Public Health 2021, 18, x

Int. J. Environ. Res. Public Health 2021, 18, 3441 3 of 15

type 3 (combined), and type 4 (bullous). There is no consensus or standardizatio
ideal classification system, and this creates difficulty and confusion in assessing
ness of any given technique for surgical reduction of inferior turbinate hypertro
effectiveness of any given technique for surgical reduction of inferior turbinate hypertrophy.
prefer the Camacho classification system [7] in our clinical practice, as it provid
We prefer the Camacho classification system [7] in our clinical practice, as it provides an
jective, practical,
objective, andreliable
practical, and reliable assessment.
assessment. It is It is imperative
imperative duringduring the evaluation
the evaluation to to
the presence
exclude of septal
the presence deviation,
of septal deviation,allergic rhinitis,oror
allergic rhinitis, unilateral
unilateral inferior
inferior turbinate h
turbinate
phy [9]. The concomitant conditions should be addressed simultaneously with th
hypertrophy [9]. The concomitant conditions should be addressed simultaneously with
the hypertrophied
trophied turbinate
turbinate to achieve
to achieve thebest
the bestoutcome.
outcome.

Figure
Figure 1. Nasoendoscopic
1. Nasoendoscopic grading
grading system system ofturbinate
of inferior inferior hypertrophy;
turbinate hypertrophy; grade
grade 1 is 0–25% of 1 is 0–
total
total airway
airway space
space occupied
occupied (A),
(A), grade 2 isgrade
26–50%2 occupied
is 26–50%
(B),occupied (B), grade
grade 3 is 51–75% 3 is(C),
occupied 51–75%
and occup
and grade 4 is 76–100%
grade 4 is 76–100% occupied (D).occupied (D).

Nasal obstruction owing to inferior turbinate hypertrophy can be measured objectively

Nasal obstruction owing to inferior turbinate hypertrophy can be measur
using an active anterior rhinomanometry, by measuring the differential pressure between
tively and
anterior using an active
posterior portionsanterior rhinomanometry,
of the nose by measuring
[10]. It is derived from the volume ofthe differential
airflow in
the nose, measured separately both before and after the administration of a decongestant. the v
between anterior and posterior portions of the nose [10]. It is derived from
By this way,
airflow inthe
theamount
nose,ofmeasured
mucosal or separately
bony contributionboth towards
before the andnasal obstruction
after the administra
can be estimated. Any increase in the nasal mucosal impedance caused by the nasal
decongestant. By this way, the amount of mucosal or bony contribution towards
obstruction can be identified by this evaluation, but it cannot localize the site of intranasal
obstruction
obstruction. Forcan beaccuracy,
better estimated. Anybeincrease
it should in the nasal
applied concurrently mucosal
with impedance caus
acoustic rhinometry.
nasal
The obstruction
reflection cansignal
of acoustic be identified by this nasal
by the respective evaluation,
anatomical butcomponents
it cannot localize
forms the s
tranasal obstruction. For better accuracy, it should be applied concurrently with
the basis of acoustic rhinometry measurement [10]. By this means, the volume of all
nasal sections can
rhinometry. be reflection
The measured, which allows signal
of acoustic a reliablebytopographic
the respectiveobstruction
nasaltoanatomica
be
identified. Corresponding to the active anterior rhinomanometry, the measurement before
nents forms the basis of acoustic rhinometry measurement [10]. By this means, th
and after decongestion enables it to differentiate mucosal pathology from other causes.
of all
This nasal sections
procedure has good can be measured,
reproducibility and iswhich allows
quick and a reliable
noninvasive, topographic
which makes it obstr
be identified.
advantageous forCorresponding
examination of nasal to the activeinanterior
pathology children.rhinomanometry, the measure
It has become the first-line
method to confirm the location and level of nasal obstruction, and
fore and after decongestion enables it to differentiate mucosal pathology is universally used as an fro
objective measurement of the effectiveness of medical and surgical treatments.
causes. This procedure has good reproducibility and is quick and noninvasiv
makes it advantageous for examination of nasal pathology in children. It has be
first-line method to confirm the location and level of nasal obstruction, and is un
used as an objective measurement of the effectiveness of medical and surgical tre
Int. J. Environ. Res. Public Health 2021, 18, 3441 4 of 15

1.3. Indications for Inferior Turbinate Reduction Surgery

One of the most common manifestations of chronic rhinitis is nasal obstruction. Nasal
obstruction occurs as a result of submucosal or mucosal hypertrophy associated with
increased vascularity of the inferior turbinate. Treatment of inferior turbinate hypertrophy
consists of topical intranasal corticosteroid sprays, oral antihistamines, and topical decon-
gestants. When conservative management fails within the appropriate treatment period,
surgical treatment is indicated. Generally, the consensus for the point of surgical interven-
tion is at 3 months, ensuing failure of medical therapy to resolve nasal obstruction as a
result of the turbinate hypertrophy [11]. However, if there is a concomitant rhinosinusitis,
the medical treatment could be extended up to 6 months. There are two types of surgical
techniques, the mucosal-sparing and non-mucosal-sparing, based on the preservation of
the medial mucosa of the inferior turbinate.

2. Nonmucosal Preservation Surgery

2.1. Conventional Turbinectomy
Turbinectomy involves removal of all or a portion of the inferior turbinate and may be
performed by direct visualization or with the aid of an endoscope. The degree of excision
can be anywhere from limited to complete resection depending upon the degree of the
hypertrophy and includes turbinate mucosa, soft erectile tissue, and bone. Usually the
inferior turbinate is resected using an angled scissor along its insertion at the lateral nasal
wall. Elwany et al. [12] compared partial turbinectomy against three other techniques for
inferior turbinate reduction to determine their subjective and objective outcomes. Their
study found both partial turbinectomy and laser turbinectomy outperformed the other
two techniques of inferior turbinoplasty and cryoturbinectomy in terms of relieving nasal
obstruction and improving olfaction. In addition, all four techniques did not affect mu-
cociliary clearance. However, the authors observed those patients who underwent partial
turbinectomy developed nasal discomfort, headache, atrophic changes, and postoperative
bleeding more than others. In a large trial of 457 patients, Passali et al. [13] reported that
inferior turbinectomy conferred significant relieve of nasal obstruction but was associated
with more complications, notably, intense pain, crusting, and bleeding. Atrophic rhinitis
and empty nose syndrome were recognized as late sequalae of this procedure, especially
following total turbinectomy [14]. Empty nose syndrome is a disorder characterized by
paradoxical nasal obstruction in the presence of a wide patent nasal cavity [14]. The ex-
cessive dryness may also lead to atrophic rhinitis with crusting and nasal block. Crusting
may develop due to the disruption of mucociliary clearance, raw mucosal edges, and
exposed bone. Besides cold microinstruments, turbinectomy may also be performed by
laser, electrocautery, and cryosurgery.

2.2. Laser Turbinectomy

The lasers commonly used for inferior turbinate reduction are diode and CO2 lasers.
Other type of lasers such as Neodymium-doped: yttrium aluminum garnet (Nd-YAG),
Holmium: YAG, potassium titanyl phosphate (KTP), and argon plasma lasers have been
reported [15]. The properties differ between the laser types based on their application of
contact or noncontact mode, pulsed or continuous wave emission, emitted wavelength,
and output power. The diode laser is the preferred choice for inferior turbinate reduction
as it provides accurate cutting with adequate hemostasis. It has an infrared wavelength
spectrum of 805–980 nm, apt for cutting soft tissue and suitable for endoscopic sinus
surgery. It provides a coagulation effect when the setting is at pulse mode and low power
output, and precise cutting effect with the ability to vaporize mucosa, cartilage, or bone,
at continuous mode and high energy output. A study was performed by Sroka et al. [16]
comparing the use of Holmium: YAG against diode lasers for turbinate reduction. The two
techniques showed significant improvement in nasal patency over six months and three
years postoperatively, with subjective improvement of nasal breathing described in 67.5%
of patients following Holmium: YAG laser and 74.4% following diode laser treatment.
Int. J. Environ. Res. Public Health 2021, 18, 3441 5 of 15

Both showed significant improvement of nasal flow on rhinomanometry. There were no

immediate complications such as major bleeding post-surgery for either the Holmium:
YAG or diode laser treatment, with minor complications such as pain or slight bleeding
reported in 5% to 8% of cases. A randomized clinical trial comparing diode laser with
radiofrequency was conducted by Kisser et al. [17]. The patients were randomized to
laser therapy in one arm, and the other arm was subjected to radiofrequency therapy. A
significant reduction of nasal obstruction was observed for both laser and radiofrequency
therapies after three months. There were no major complications observed, but significant
discomfort was reported in the radiofrequency arm.
Prokopakis et al. [18] compared the use of CO2 laser with radiofrequency and electro-
cautery to evaluate their outcome and effect on nasal obstruction using subjective visual
analogue scale and objective rhinomanometry. The study found 86% of patients in the
CO2 laser group reported subjective improvement in nasal obstruction, but no statistical
difference was found among these three groups. Long-term impairment of the mucocil-
iary transport and a more challenging manipulation of the device represent the major
disadvantages of CO2 laser.

2.3. Electrocautery Turbinectomy

This technique involves an application of electrical current to cauterize the turbinate
tissue either on the mucosal surface or in a submucosal plane. It is the least effective in
improving nasal airway resistance and reducing turbinate volume, with higher rates of
postoperative crusting and nasal synechiae reported [13]. When performed submucosally,
the amount of tissue destruction is hard to gauge and there is substantial risk of surrounding
tissue destruction from the excessive temperatures generated, owing to the requisite high
power and voltage.

2.4. Cryoturbinectomy
Cryotherapy is a minimally invasive procedure that uses nitrous oxide or liquid
nitrogen as a cooling agent and induces necrosis by freezing the turbinate. It works by
inducing scarring and direct destruction of mucosa and submucosal erectile tissue. The
overall short-term results are satisfactory, but the benefit is usually not sustainable. The
amount of volume reduction is hard to predict, and compared to the other methods, it
has dismal long-term results [13]. Cryosurgery was later gradually abandoned due to the
availability of new techniques enabling better procedures to be performed.

3. Mucosal Preservation Surgery

3.1. Conventional Turbinoplasty
This surgery is designed to remove the nonfunctional obstructive part of the turbinate
while preserving the functional medial mucosa, which plays the key role in the warming
and humidification of air through the nasal passages. Performed endoscopically, infe-
rior turbinoplasty has the advantage over the other turbinate procedures by preserving
sufficient mucosa, while removing adequate obstructed tissue to improve the airway signifi-
cantly. The other term used for this technique is “submucosal resection”, as a reference to its
submucosal dissection procedure. There are two types of turbinoplasty: intraturbinoplasty
and extraturbinoplasty [19]. An intraturbinoplasty is a technique involving tunneling
inside the turbinate, which only removes the submucosal erectile tissue, leaving behind
the bulky inferior turbinate bone. This procedure is meant to address inferior turbinate
hypertrophy contributed by the soft erectile tissue. When both soft erectile tissue and
turbinate bone are removed, it is designated as an extraturbinoplasty. The extraturbino-
plasty is a modification of an inferior turbinoplasty that combines conservative sparing of
the nasal mucosa together with the removal of the obstructing soft tissue and part of the
bulky inferior turbinate bone. An intraturbinoplasty may be performed by microdebrider,
coblation, radiofrequency, and ultrasound, whereas extraturbinoplasty may be performed
by microinstruments, coblation, and microdebrider.
Int. J. Environ. Res. Public Health 2021, 18, x 6 of 15

the bulky inferior turbinate bone. An intraturbinoplasty may be performed by microdeb-

Int. J. Environ. Res. Public Health 2021, 18, 3441 coblation,
rider, radiofrequency, and ultrasound, whereas extraturbinoplasty may 6 of 15
be per-
formed by microinstruments, coblation, and microdebrider.
An extraturbinoplasty utilizing the medial mucosa as a medial flap to cover the raw
edges
Anof resected lateral mucosa
extraturbinoplasty utilizingand soft erectile
the medial mucosa tissue
as a is initially
medial flapstarted
to cover asthe
a nonendo-
raw
scopicofprocedure
edges [20]. One
resected lateral mucosaof the
andobservations by Mabry
soft erectile tissue in hisstarted
is initially series was that over 30%
as a nonendo-
of his procedure
scopic patients failed to obtain
[20]. One of therelief from postnasal
observations by Mabry discharge andwas
in his series rhinorhea
that over at 30%
one year
and
of hismore
patientspostoperatively
failed to obtain [20]. This
relief fromwaspostnasal
attributed to an excessive
discharge mucosal
and rhinorhea preservation,
at one year
and more postoperatively
as without an endoscope[20]. This was
to guide the attributed
resection,to anvolume
the excessive ofmucosal
reduction preservation,
was imprecise.
as without anetendoscope
Putterman al. [21] later to guide
reportedthe resection, the volume
a modification of an of reduction was imprecise.
extraturbinoplasty, which was
Putterman
performedetendoscopically.
al. [21] later reportedThis atechnique
modification of an extraturbinoplasty,
involved making an incision which
at thewas per- in-
anterior
formed endoscopically. This technique involved making an incision at
ferior turbinate using cold instruments such as sickle knife or micro scissor. The incision the anterior inferior
turbinate using downwards
was extended cold instruments such as
and along sickle
the knifesurface
inferior or micro scissor. The
of inferior incision
turbinate to was
its poste-
extended downwards and along the inferior surface of inferior turbinate to its posterior end.
rior end. Using microinstruments (microscissor and/or cutting forceps), the whole lateral
Using microinstruments (microscissor and/or cutting forceps), the whole lateral aspect
aspect of the inferior turbinate mucosa and soft tissue were removed in an anterior to
of the inferior turbinate mucosa and soft tissue were removed in an anterior to posterior
posterior direction. The turbinate bone was dissected off the soft tissue using a freer dis-
direction. The turbinate bone was dissected off the soft tissue using a freer dissector or
sector or microscissor
microscissor to separateto separate
it from it from mucosa
the medial the medial mucosa
of the inferior ofturbinate,
the inferior andturbinate,
forceps and
was used to remove it (Figure 2). The resected posterior end of the inferior turbinate wasturbi-
forceps was used to remove it (Figure 2). The resected posterior end of the inferior
nate was to
cauterized cauterized to prevent postoperative
prevent postoperative bleeding. Followingbleeding. the Following
removal of bonethe removal
and lateral of bone
and lateral
mucosa, mucosa,
the medial the medial
mucosa was rotatedmucosa was to
laterally rotated laterally
cover the remainingto cover
exposedthearea
remaining
of the ex-
posedpart
lateral areaofofthethe lateral
inferior part of the
turbinate. inferior turbinate.
A modification A modification
of this technique of this technique
using microdebrider
using
was microdebrider
later performed by was later performed
Barham et al. [22]. by Barham et
Employing al.procedure
this [22]. Employing
to treatthis procedure
patients
suffering from inferior turbinate hypertrophy attributed to allergic and
to treat patients suffering from inferior turbinate hypertrophy attributed to allergic and nonallergic rhinitis,
Hamerschmidt et al. [23]
nonallergic rhinitis, reported a marked
Hamerschmidt improvement
et al. [23] reported ainmarked nasal obstruction
improvement (94.7%).in nasal
Besides a reduction of nasal obstruction, their patients also demonstrated
obstruction (94.7%). Besides a reduction of nasal obstruction, their patients also demon- improvement
in snoring
strated (89.5%), smell
improvement in(100%),
snoringfacial pressure
(89.5%), smell(95.5%),
(100%), and facialallergy symptoms
pressure (95.5%),ofand nasalallergy
itching, runny nose, and sneezing (89.7%).
symptoms of nasal itching, runny nose, and sneezing (89.7%).

Figure2.2.InInconventional
Figure conventional turbinoplasty,
turbinoplasty, a freer
a freer elevator
elevator dissects
dissects the turbinate
the turbinate bone bone anderectile
and soft soft erec-
tile tissue (A) and a Blakeley’s forceps later removes part of the soft tissue and
tissue (A) and a Blakeley’s forceps later removes part of the soft tissue and bone (B). bone (B).

3.2.
3.2.Microdebrider
MicrodebriderTurbinoplasty
Turbinoplasty
Following
Followingitsitsintroduction
introduction in in
thethe
otorhinolaryngological
otorhinolaryngological specialty, the microdebrider
specialty, the microdebrider
made
made a significant advancement in endoscopic sinus surgery [24]. It becamewidely
a significant advancement in endoscopic sinus surgery [24]. It became widely ac-
accepted
cepted as as aa useful
useful tool
toolfor
forsinus
sinussurgery
surgerywith
withthethe
capability of continuously
capability of continuously suctioning
suctioning
blood from the operative site, allowing better surgical visual field and permitting precise
blood from the operative site, allowing better surgical visual field and permitting precise
tissue removal in a mucosal-sparing manner. Barham et al. [22] described the steps of using
tissue removal in a mucosal-sparing manner. Barham et al. [22] described the steps of us-
a microdebrider for an extraturbinoplasty medial flap technique. A window was created
ing a microdebrider for an extraturbinoplasty medial flap technique. A window was cre-
at the anterior inferior turbinate using the microdebrider blade. Using the microdebrider
ated at
blade, thethe anterior
whole inferior
lateral aspect turbinate using
of the inferior the microdebrider
turbinate mucosa and blade. Using
soft erectile the microdeb-
tissue were
rider blade,
removed in anthe wholeto
anterior lateral aspect
posterior of the inferior
direction turbinate
(Figure 3). mucosa
The turbinate andwas
bone softdissected
erectile tissue
were
off theremoved inusing
soft tissue an anterior
a cottletodissector
posteriortodirection
separate(Figure
it from 3).
theThe turbinate
medial mucosa bone was dis-
of the
sected turbinate
inferior off the soft tissueflap),
(medial usinganda cottle dissector
a Blakesley to separate
forceps was usedittofrom
removetheit.medial
If theremucosa
was of
any bleeding encountered, bipolar cautery was used for hemostasis. Postremoval of bone
Int. J. Environ. Res. Public Health 2021, 18, x 7 of 15

Int. J. Environ. Res. Public Health 2021, 18, 3441 7 of 15

the inferior turbinate (medial flap), and a Blakesley forceps was used to remove it. If there
was any bleeding encountered, bipolar cautery was used for hemostasis. Postremoval of
and
bonelateral
and mucosa, the medial
lateral mucosa, theflap was flap
medial placed
wasin placed
its finalin
position curving
its final inferolaterally
position curving inferol-
toaterally
cover the remaining exposed area of the lateral inferior turbinate.
to cover the remaining exposed area of the lateral inferior turbinate.

Figure3.3.Microdebrider
Figure Microdebrider blade
blade is placed
is placed at the
at the lateral
lateral partpart of the
of the left left turbinate
turbinate to dissect
to dissect the lateral
the lateral
mucosal wall and turbinate bone from anterior (A) to posterior (B)
mucosal wall and turbinate bone from anterior (A) to posterior (B) direction. direction.

InIna aprospective,
prospective, randomized,
randomized, comparative
comparative trialtrial by Joniau
by Joniau et al.et[25],
al. [25], microdebrider
microdebrider
turbinoplasty was compared against electrocautery in patients with chronic nasal
turbinoplasty was compared against electrocautery in patients with chronic nasal obstruc-obstruc-
tion
tionsecondary
secondarytoto inferior
inferior turbinate
turbinate hypertrophy.
hypertrophy. Subjective
Subjectivesymptoms
symptoms questionnaires,
questionnaires,
endoscopic
endoscopicscoring, scoring, andand acoustic
acoustic rhinometry
rhinometry showed
showedmicrodebrider
microdebrider turbinoplasty
turbinoplastywas was
the superior method in achieving relief of nasal obstruction. Rapid
the superior method in achieving relief of nasal obstruction. Rapid reduction of inferior reduction of inferior
turbinate
turbinate size
sizewas apparent
was apparent at one week
at one postoperatively
week postoperatively and persisted until one
and persisted year.
until oneNasal
year. Na-
breathing was better, and no crusting was observed. The observed
sal breathing was better, and no crusting was observed. The observed changes were con- changes were confirmed
by acoustic rhinometry. Improvement of nasal obstruction and size reduction were slower
firmed by acoustic rhinometry. Improvement of nasal obstruction and size reduction were
in electrocautery, attained at three weeks, with relapse at one year. Another study evaluated
slower in electrocautery, attained at three weeks, with relapse at one year. Another study
the objective outcome by total nasal resistance using anterior rhinomanometry in patients
evaluated
with substantialthe objective outcome
nasal congestion due bytototal nasal allergic
perennial resistance using
rhinitis anterior
[26]. rhinomanometry
Post microdebrider
in patients with
turbinoplasty, substantial
the total nasal congestion
nasal resistance significantly duedecreased
to perennial fromallergic
0.45 Pa/cm rhinitis
3 per[26].
sec- Post
ond preoperatively to 0.28 Pa/cm per second at one year postoperatively. Besides the 0.45
microdebrider turbinoplasty, the3 total nasal resistance significantly decreased from
Pa/cm3 per
reduction second
of nasal preoperatively
resistance, to 0.28
their quality Pa/cm
of life also3 per second
showed at one year
significant postoperatively.
improvement.
Besides the reduction
As a surgical tool, the ofmicrodebrider
nasal resistance, has atheir quality
distinct of lifefor
advantage also
itsshowed significant
versatility. Besides im-
provement.
its application in extraturbinoplasty, it can also be used for an intraturbinoplasty or endo-
scopicAs a surgical
sinus surgery tool,
for a the microdebrider
concomitant has a distinct
rhinosinusitis when this advantage for its
is necessary. Theversatility.
surgical Be-
steps
sidesofitsanapplication
intraturbinoplasty were described by
in extraturbinoplasty, Lee also
it can et al.be
[27]. Anfor
used intraturbinoplasty
an intraturbinoplastywas or
performed
endoscopic bysinus
initially creating
surgery for aaconcomitant
submucosal rhinosinusitis
pocket at the anterior
when this pole of the inferior
is necessary. The sur-
turbinate.
gical stepsThe of anmicrodebrider
intraturbinoplasty was then were inserted
described to resect
by Leeand remove
et al. [27]. Antheintraturbinoplasty
submucosal
erectile tissue with or without the turbinate bone removal.
was performed by initially creating a submucosal pocket at the anterior pole Both the medial andoflateral
the inferior
mucosal surfaces were preserved.
turbinate. The microdebrider was then inserted to resect and remove the submucosal erec-
The application of the microdebrider as an intraturbinoplasty method has been shown
tile tissue with or without the turbinate bone removal. Both the medial and lateral mucosal
to have parallel outcome to that of extraturbinoplasty technique. Lee [19] conducted
surfaces were preserved.
a comparative study between microdebrider intraturbinoplasty and extraturbinoplasty
The and
techniques application
showed that of thebothmicrodebrider
methods exhibited as an intraturbinoplasty
significant improvementmethod has been
in the degree
shown to have parallel outcome to that of extraturbinoplasty
of nasal obstruction, rhinorrhea, sneezing, nasal itching, and postnasal drip 12 months technique. Lee [19] con-
ducted a comparative study between microdebrider intraturbinoplasty
postoperatively, but the intraturbinoplasty method had an edge of a shorter operative and extraturbi-
noplasty
time. Anothertechniques and showed
study compared that both methods
microdebrider exhibited significant
intraturbinoplasty improvement in
with the conventional
the degree ofmethod
turbinoplasty nasal obstruction, rhinorrhea,
[28]. Both techniques were sneezing,
shown tonasal itching,improve
significantly and postnasal
the nasal drip 12
months postoperatively,
symptoms and increase volume but the
of theintraturbinoplasty
nasal patency, butmethod had anintraturbinoplasty
microdebrider edge of a shorter op-
had statistically
erative significant
time. Another study lower blood microdebrider
compared loss and a shorter operative time. with
intraturbinoplasty Hence,thetheconven-
study
tionalconcluded
turbinoplasty that it provides
method marked
[28]. improvements
Both techniques wereinshown
nasal obstruction
to significantlyand hasimprove
the
theadvantage
nasal symptoms of mucosalandpreservation
increase volume alongsideof thecontrolled volumebut
nasal patency, reduction, minimalintra-
microdebrider
trauma, reduced bleeding, and enhanced precision.
turbinoplasty had statistically significant lower blood loss and a shorter operative time.
Int. J. Environ. Res. Public Health 2021, 18, 3441 8 of 15

A comparative study was conducted by Cingi et al. [29] to assess microdebrider

turbinoplasty with radiofrequency turbinoplasty. Patients were assigned to the microde-
brider arm and the radiofrequency arm. Symptom improvement was statistically significant
in microdebrider group on the seventh day and first and third months after surgery. The
rhinomanometric measurements showed wider nasal patency in the microdebrider group
when compared against the radiofrequency group. However, the use of microdebrider still
has risk of postoperative bleeding. A study by Lee et al. [27] found 30% of patients devel-
oped postoperative nasal bleeding, requiring temporary packing with epinephrine-soaked
gauze following microdebrider intraturbinoplasty. The average intraoperative blood loss
was about 10 mL, with other minor issues such as crusting, synechiea, and throat dryness.
The authors compared their results to those performed in European patients and postulated
that Asian and Caucasian noses have a different innate immunological mechanism. Due to
this, they recommended under-resection of the intraturbinal tissue to prevent some of the
complications observed.

3.3. Coblation Turbinoplasty

Coblation is a unique method of delivering radio frequency energy to the soft tissue
for applications in otolaryngology. By using radio frequency in a bipolar mode with a
conductive solution, such as saline, it energizes the ions in the saline to form a small
plasma field. The decreased thermal effect consequently leads to less pain and faster
recovery for cases where tissue is excised [30]. Coblation induces reduction of the inferior
turbinate by vaporizing and destroying the soft erectile tissue. The volume reduction
and tissue fibrosis are immediate and sustainable. Further swelling and hypertrophy
of inferior turbinate are prevented by contracture and anchoring of the mucosa to the
periosteum as a result of the fibrosis. Coblation technology may be performed as an
intraturbinoplasty or extraturbinoplasty technique (Figure 4). Plain saline is initially
injected in the turbinate before its activation and insertion. Passali et al. [31] performed a
coblation intraturbinoplasty by using the Coblator II surgery system and a Reflex Ultra
45 wand set at power level four. After activation, the tip of the wand was introduced
at the anterior part of the inferior turbinate to create a horizontal channel from anterior
to posterior. The wand was advanced along the length of the turbinate submucosally.
Depending on the bulk of the turbinate, these steps could be repeated by creating an
additional one to two channels. Using this surgical technique, they compared it with
radiofrequency turbinoplasty and other techniques. Both coblation and radiofrequency
were found to have comparable outcomes in improving the nasal patency and relieving the
nasal blockage. The outcome of both coblation and radiofrequency was better than that
of conventional turbinoplasty but equivalent to that of conventional turbinectomy with
minimal complications.
Di Rienzo Businco et al. [32] conducted a study to determine the efficacy of coblation
tunneling technique on patients with persistent inferior turbinate hypertrophy. The proce-
dure was done by inserting the coblation wand tip through the anterior head of inferior
turbinate all the way posteriorly in a submucosal compartment. Postoperatively, both
subjective symptoms score and objective rhinomanometry evaluation showed significant
improvement in their symptoms and apparent turbinate size reduction. None of the partic-
ipants experienced any major adverse effects such as bleeding, synechia formation, and
rhinitis sicca during or after the procedure.
To investigate the coblation’s effect in children with inferior turbinate hypertrophy,
a study was conducted on patients aged 6 to 18 years old [33]. The study found the
subjective nasal obstruction achieved 100% improvement as the preoperative symptom
score dropped significantly, from 9 (range, 7–10) to 0 postoperatively. Hence, this technique
has been shown to be a safe and effective technique for the treatment of children with
nasal obstruction, with none of the patients experiencing mucosal ulceration, adhesions,
or other complications. The short-term beneficial effect of coblation at three months was
further demonstrated subjectively and objectively by Farmer et al. [34], with significant
Int. J. Environ. Res. Public Health 2021, 18, 3441 9 of 15

improvement in nasal resistance assessed by rhinomanometry and the visual analogue

scale for nasal obstruction. To determine the long-term effect of coblation, the same
investigators [35] followed their patients for of up to 32 months. They observed sustained
Int. J. Environ. Res. Public Health 2021, 18, x
improvement in the subjective nasal obstruction and objective nasal resistance over the 9 of 15
long term.

Figure4.4.Coblation
Figure Coblation turbinoplasy
turbinoplasy applied
applied as an
as an intraturbinoplasty
intraturbinoplasty technique
technique (A) and
(A) and extraturbi-
extraturbino-
noplasty technique
plasty technique (B). (B).

To weakness
The investigate ofthe coblation’s
coblation’s effect
Reflex in children
Ultra with
wand is its inferior
limited turbinate
effect hypertrophy,
on the turbinate
a study
bone. was conducted
To surmount on patients
this limitation, theaged 6 to 18wand
Turbinator yearswas
olddeveloped
[33]. The study found the sub-
and introduced.
The Reflex
jective Ultra
nasal is shaped as
obstruction a fine-tipped
achieved 100%wand and was designed
improvement to shrink thesymptom
as the preoperative turbinate score
soft tissue significantly,
dropped using thermalfrom energy. In contrast,
9 (range, 7–10)the
to 0Turbinator has a wide
postoperatively. tip with
Hence, thermal has
this technique
effect similar to that of a Reflex Ultra but has a cutting effect comparable
been shown to be a safe and effective technique for the treatment of children with to that of a nasal
microdebrider. Thus, in addition to its thermal effect on the soft tissue,
obstruction, with none of the patients experiencing mucosal ulceration, adhesions, or it has the ability
toother
dissect the soft erectile
complications. Thetissue from turbinate
short-term bone.
beneficial Inof
effect a study
coblationby Mehta
at three et months
al. [36], the
was fur-
Turbinator wand was compared with the Reflex Ultra wand. In one arm, the patients were
ther demonstrated subjectively and objectively by Farmer et al. [34], with significant im-
subjected to turbinoplasty with Turbinator, and the other arm underwent Reflex Ultra.
provement in nasal resistance assessed by rhinomanometry and the visual analogue scale
Visual analogue scale and endoscopic assessments were done postoperatively at day 7, first
for nasal obstruction. To determine the long-term effect of coblation, the same investiga-
month, third month, and first year. Both groups reported significant and matching results
intors
the[35]
longfollowed
term, buttheir patients for
an immediate of up to 32 months.
improvement They
at one week observed
was seen in sustained improve-
the Turbinator
group only. The significant difference in the outcome is accredited to the Turbinator’s term.
ment in the subjective nasal obstruction and objective nasal resistance over the long
cuttingThe weakness
action of coblation’s
on the submucosal Reflex
tissue Ultratissue,
and bony wandleading
is its limited effect reduction
to an instant on the turbinate
in
bone.
the To surmount
turbinate’s size and this limitation,
symptom the Turbinator wand was developed and introduced.
improvement.
The Reflex Ultra is shaped as a fine-tipped wand and was designed to shrink the turbinate
3.4.
softRadiofrequency
tissue using Turbinoplasty
thermal energy. In contrast, the Turbinator has a wide tip with thermal
Radiofrequency
effect similar to thatturbinoplasty
of a Reflex Ultrais a minimally invasive
but has a cutting technique
effect that reduces
comparable to thattheof a mi-
turbinate volume in a precise and targeted manner. It uses radiofrequency to reduce
crodebrider. Thus, in addition to its thermal effect on the soft tissue, it has the ability to the
tissue
dissectvolume witherectile
the soft minimal impact
tissue on surrounding
from tissues
turbinate bone. In[37]. Radiofrequency
a study by Mehta et is mainly
al. [36], the
applied as an intraturbinoplasty method (Figure 5). The surgical steps are
Turbinator wand was compared with the Reflex Ultra wand. In one arm, the patients similar to those were
ofsubjected
coblation,toexcept there is no
turbinoplasty saline
with necessaryand
Turbinator, for its
theapplication.
other arm Li et al. [38] Reflex
underwent demon-Ultra.
strated radiofrequency-relieved nasal obstruction with a total mean reduction of 56.5%
Visual analogue scale and endoscopic assessments were done postoperatively at day 7,
postoperatively and with minimal adverse effects. The use of radiofrequency involves en-
first month, third month, and first year. Both groups reported significant and matching
ergy in the range of 60 ◦ C to 90 ◦ C, which minimizes excessive tissue injury and limits heat
results in the long term, but an immediate improvement at one week was seen in the Tur-
dissipation. Other studies demonstrated identical effects of radiofrequency in their patients.
binator
The groupimprovement
significant only. The significant difference in
of nasal obstruction theachieved
was outcomeinis85.5%
accredited to thewith
of patients Turbina-
none or mild postoperative pain [13,37,39–41]. There were only minimal adverse reactionsreduc-
tor’s cutting action on the submucosal tissue and bony tissue, leading to an instant
tion in the
reported, turbinate’s
such sizeadhesion,
as crusting, and symptom improvement.
dryness, or nasal bleeding. All studies reported
significant nasal flow increase on rhinomanometric measurements, with an average of 55%
3.4. Radiofrequency
decrease Turbinoplasty
in the severity of nasal obstructive symptoms [13,41,42]. A comparative study
Radiofrequency turbinoplasty is a minimally invasive technique that reduces the tur-
binate volume in a precise and targeted manner. It uses radiofrequency to reduce the tis-
sue volume with minimal impact on surrounding tissues [37]. Radiofrequency is mainly
applied as an intraturbinoplasty method (Figure 5). The surgical steps are similar to those
 dissipation. Other studies demonstrated identical effects of radiofrequency in their pa-
tients. The significant improvement of nasal obstruction was achieved in 85.5% of patients
with none or mild postoperative pain [13,37,39–41]. There were only minimal adverse re-
actions reported, such as crusting, adhesion, dryness, or nasal bleeding. All studies re-
Int. J. Environ. Res. Public Health 2021, 18, 3441 significant nasal flow increase on rhinomanometric measurements, with
ported 10 ofan
15 aver-
age of 55% decrease in the severity of nasal obstructive symptoms [13,41,42]. A compara-
tive study between radiofrequency turbinoplasty and microdebrider turbinoplasty
demonstrated
between a markedturbinoplasty
radiofrequency significant improvement in nasal
and microdebrider flow with nodemonstrated
turbinoplasty significant differ-
a marked significant improvement in nasal flow with no significant differencethese
ence either in visual analogue scale or in rhinomanometry score between eithertwoin tech-
niques
visual [43]. Ascale
analogue study that
or in assessed clinical
rhinomanometry scoreoutcomes
between of radiofrequency
these two techniquesturbinoplasty
[43]. A
against
study thatconventional turbinectomy
assessed clinical outcomes ofreported good improvement
radiofrequency of the nasal
turbinoplasty against function and
conventional
turbinectomy
similar volume reported goodofimprovement
reduction of the nasal
the inferior turbinates infunction and similar
both methods volume re-
[44]. However, muco-
duction of the inferior
ciliary function turbinatestoin
was observed beboth methods
affected more[44]. However,
in the mucociliary
conventional functionInter-
turbinectomy.
was observed
estingly, to be study
another affected more inthat
reported the conventional turbinectomy.
treating patients Interestingly,
who had both another and
septal deviations
study reported that treating patients who had both septal deviations and inferior
inferior turbinate hypertrophy by radiofrequency turbinoplasty alone had similar results turbinate
hypertrophy
with those whoby radiofrequency
were treated byturbinoplasty alone had similar
a combined radiofrequency results with and
turbinoplasty thoseseptoplasty
who
were treated by a combined radiofrequency turbinoplasty and septoplasty [45].
[45].

Figure5.5.Radiofrequency
Figure Radiofrequency probe
probe is inserted
is inserted at anterior
at anterior headhead of inferior
of the the inferior turbinate
turbinate and pushed
and pushed in in
an anterior (A) to posterior (B) direction.
an anterior (A) to posterior (B) direction.

3.5.
3.5.Ultrasound
UltrasoundTurbinoplasty
Turbinoplasty
Ultrasound
Ultrasoundtechnology
technologyforfor rhinologic
rhinologic surgery
surgeryis aisrelatively
a relativelynewer technique.
newer technique.
Gindros et al. [46] used the Lora Don 3 equipment (Diamant Co., Thessaloniki,
Gindros et al. [46] used the Lora Don 3 equipment (Diamant Co., Thessaloniki, Greece) Greece) to to
treat their patients with inferior turbinate hypertrophy. They performed
treat their patients with inferior turbinate hypertrophy. They performed it by inserting an it by inserting
an activatedultrasonic
activated ultrasonicnasal
nasalprobe
probesubmucosally
submucosallythroughthrough thethe inferior
inferior turbinate
turbinate andand ad-advanc-
vancing it along its length. Then, the probe was moved in a forward–backward movement
ing it along its length. Then, the probe was moved in a forward–backward movement in
in a slow and gentle manner. At the end of this process, the nasal probe was withdrawn
a slow and gentle manner. At the end of this process, the nasal probe was withdrawn from
from the turbinate tissue. These steps can be repeated in extensive turbinate enlargement
the turbinate tissue. These steps can be repeated in extensive turbinate enlargement by
by creating one or two more parallel tunnels. Exposure of the affected tissues of inferior
creating to
turbinate one or two more
submucous parallel tunnels.
low-frequency Exposure
fluctuation of anofultrasonic
the affected nasaltissues
probeofresulted
inferior tur-
binate to submucous low-frequency fluctuation of an ultrasonic
in destruction of the cavernous and connecting tissues, with subsequent reduction of nasal probe resulted
the in
destruction
volume of the of the cavernous
turbinate. Thus, fastand connecting
restoration tissues,
of nasal with and
function subsequent
respiratoryreduction
functionof the
volume of the
could be obtained. turbinate. Thus, fast restoration of nasal function and respiratory function
could be obtained.
Gindros et al. [46] enrolled patients with medically refractory chronic nasal obstruction
due toGindros
inferior et al. [46] enlargement;
turbinate enrolled patients with medically
one group underwent refractory chronic nasal
inferior turbinate volumeobstruc-
reduction
tion due using ultrasound
to inferior procedure
turbinate on the left
enlargement; oneside and underwent
group monopolar diathermy on the vol-
inferior turbinate
right,
ume and the other
reduction group
using underwent
ultrasound coblation on
procedure technique
the left on
sidetheandleftmonopolar
side and ultrasound
diathermy on
turbinate
the right, and the other group underwent coblation technique on thegreat
reduction on the right. Most patients of all groups experienced improve-
left side and ultra-
ment
sound of turbinate
their symptoms.
reductionVisual
on theanalogue scale patients
right. Most scores were better
of all groupsin the group treated
experienced great im-
by ultrasound in comparison with those treated by coblation and
provement of their symptoms. Visual analogue scale scores were better in the group electrocautery. This
improvement was further confirmed by objective testing, which showed the ultrasound
treated by ultrasound in comparison with those treated by coblation and electrocautery.
turbinate reduction procedure had better results, with decreased nasal resistance, increased
nasal flow, and significant increase in nasal patency.
Int. J. Environ. Res. Public Health 2021, 18, 3441 11 of 15

4. Adjunct Technique
Out-fracture of the inferior turbinate may be performed with other turbinate reduction
techniques. It involves lateral displacement of the inferior turbinate by an initial in-fracture,
moving it medially from its attachment at the lateral nasal wall. The basis of doing this
procedure is to create additional space when inferior turbinate is lateralized. Its efficacy is
variable, resulting in much criticism over its role. As there is a tendency for the turbinate
to return to its original position, it is not recommended as a single procedure, but it may be
used to supplement the other techniques [13].

5. Differences and Similarities of Surgical Approach to Inferior Turbinate

Hypertrophy between Children and Adults
When compared to adults, turbinate reduction surgery in children is contentious and
debatable. The considerations are whether the benefits outweigh the risks, and medical
therapy should always be optimized before surgical therapy is contemplated. The ap-
prehension is of needless complications like excessive bleeding, damage to the mucosa
with synechie and tear, disruption of nasal physiology and function, and disturbance of
facial growth and development. Hence, any surgery of turbinates in childhood should be
limited to avoid unwarranted complications. With this in mind, a conservative procedure
involving turbinate reduction is ideal, whereby the turbinate mucosa is preserved, allowing
the procedure to be accomplished without any harmful effect.
Nonetheless, several studies carried out in children have not shown any significant
harmful effects. Partial or total turbinectomies carried out in children aged between 9 and
15 years old achieved a success rate of 68% without any complications such as bleeding,
synechia, or olfactory dysfunction [47]. A total turbinectomy performed in children less
than 16 years was found to attain a success rate of 91% without any reported complications
of crusting, atrophic rhinitis, or ozaena [48]. Another study of total turbinectomy in
children less than 10 years old showed effectiveness approximately of 80%, but 6% of
children developed synechiea formation [49]; no midfacial growth was noted with a follow-
up period of over 14 years.
With the available newer technologies such as microdebrider or radiofrequency per-
formed as an intraturbinoplasty technique, such procedures can be performed as mucosal-
sparing methods with greater efficacy and minimal postoperative complications [50].
Remarkably, the mucosal-sparing approach has been shown to be safe and efficacious
when performed concurrently with other procedures such as adenotonsillectomy [51]. Due
to limited data and uncertainty over the long-term adverse effects, the decision to perform
surgical turbinate reduction in children depends on clinical judgement and the preference
of patients or their guardians/parents. In terms of surgical steps, there are no differences
between children and adults.

6. Effects of Inferior Turbinate Surgery on Nasal Physiology and Function

In hypertrophied turbinate mucosa, histological examination revealed that there is
an overall increase of the lamina propria width together with the thickening of mucosa
overlying the medial portion of the turbinate, which accounted for the turbinate size
increase [52]. In addition, there is also engorgement of the venous sinusoid within the
hypertrophied turbinate. The connective tissue, submucosal glands, and vessels, however,
remained relatively unchanged. Postoperatively, it is important to maintain the function of
the mucociliary clearance by preserving the mucosal surface epithelium. Any procedure
targeting a reduction in the size of the turbinates should be able to improve or preserve
the mucosal morphology alongside improvement of the nasal airway. A reflection of these
can be seen from the presence of normal epithelial goblet cells, lamina propria glands,
vasculature, and tissue eosinophilia in the mucosal epithelium to indicate the restoration
of epithelial function. One study reported reduction of submucosal glands and venous
sinusoids, epithelial stripping, significant fibrosis, and pockets of squamous metaplasia in
Int. J. Environ. Res. Public Health 2021, 18, 3441 12 of 15

the operated areas [53]. In contrast, the epithelial structure showed normal nasal mucosa
following surgery in another study, believed to be due to its regenerative capacity [54].
A study demonstrated that the cross-sectional area of the nasal cavity in patients with
chronic nasal obstruction requiring septorhinoplasty procedure significantly changed when
turbinate reduction surgery was added to the former procedure [55]. Acoustic rhinometry
postoperatively revealed that the minimal cross-sectional area at the level of the nasal
valve significantly increased in patients with the additional turbinate reduction surgery
compared with those without. To determine the effect of inferior turbinate surgery on
nasal physiology, a study was performed by Pelen et al. [56]. An acoustic rhinometry was
performed on patients suffering from chronic nasal obstruction following two techniques;
one group treated by radiofrequency and the other group treated by microdebrider. Both
techniques were shown to be effective in relieving obstruction without any disruption of
the nasal physiology.

7. What Is the Ideal Surgical Technique for the Reduction of Inferior

Turbinate Hypertrophy?
Even though there is no gold standard in treating turbinate hypertrophy, in a best
practice review [57], microdebrider turbinoplasty has been shown to be the most effective
and safe. The review highlighted that ultrasound turbinoplasty is the next most promising
technology and has the potential to be the leading surgical technique. Based on the present
review, we support microdebrider turbinoplasty as one of the recommended techniques,
but there is recent evidence that radiofrequency technology, particularly coblation, may
also offer corresponding benefits [58]. Both have strong evidence from clinical trials and
studies to demonstrate their efficacy and safety. Unfortunately, ultrasound turbinoplasty
has never caught on, and there is scarcity of data to support its role in turbinate reduction.
Moreover, both microdebrider turbinoplasty and radiofrequency technology have the
advantage of widespread use and familiarity. On the other hand, there are other factors
that should be considered in determining the outcome, such as criteria for patient selection.
Turbinate hypertrophy consists of either mucosal or osseous hypertrophy or both, and a
proper evaluation prior to surgery could assist in deciding the best technique to address
the contributing components of the obstructed nose.
Nevertheless, there appears to be a significant detachment between current practices
and the recommended surgical method, as can be seen by the wide availability of tech-
niques being performed. It is noteworthy that the results of a survey of the “American
Society for Aesthetic Plastic Surgery”, which includes practicing plastic surgeons and
otorhinolaryngologists, showed 61.9% of respondents prefer conventional turbinoplasty,
35.2% prefer out-fracture of inferior turbinate (as a sole procedure), and only 8.6% give
radiofrequency technology as their preferred surgical management strategy for inferior
turbinate hypertrophy [59]. There appears to be disparity between clinical practice and
medical evidences. It is concerning, as this may result in poor decision-making and se-
lecting technique with inferior outcome. The conflict may be explained by confusion over
the variety of available surgical techniques and lack of understanding of the rationale
for performing the turbinate reduction. Besides providing a concise overview of each
technique, hopefully this review can also serve as a guide to choose the optimal technique
for turbinate reduction.

8. Conclusions
The main goals of surgical reduction of inferior turbinate hypertrophy are the relief
of nasal obstruction and avoiding complications such as bleeding, crusting, and excessive
pain. It is indicated and could be the treatment of choice when nasal block is refractory
to medications. Although there is lack of consensus on the ideal methods, techniques
such as microdebrider turbinoplasty and radiofrequency technology appear to have the
advantage. Irrespectively, a judicious and cautious approach to turbinate resection is
required to prevent complications. Which technique to perform may ultimately depend on
the clinical practice, clinical skill, and experience of the surgeons.
Int. J. Environ. Res. Public Health 2021, 18, 3441 13 of 15

Author Contributions: Conception and design: B.A. and S.S.; acquisition, analysis, and interpretation
of data: B.A. and S.S.; drafting of the article: B.A. and S.S.; critical revision of the article: B.A. and S.S.;
study supervision: B.A.; review of the submitted version of the manuscript: all authors. All authors
have read and agreed to the published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Data Availability Statement: No new data were created or analyzed in this study. Data sharing is
not applicable to this article.
Conflicts of Interest: The authors declare no conflict of interest.

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